Clinical Audit Supplement Quality Account 2011-2012
Contents
Section Number
Section Title
Page No
1 2 3 4
Introduction UHCW Audit Participation National Audit Local Audit
3 3 5 6
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
2
1. Introduction This clinical audit supplement has been developed to augment the information provided in the UHCW Quality Account, Section 5.2. It provides additional detail as to the review of and benefits gained through participation in both national and local audits and the rationale for non participation in national audits listed in the Quality Account Clinical Audit List published by the Department of Health. Participation rates for audits that UHCW participated in 2011/2012 are detailed in the main Quality Account document.
2. Clinical Audit Non-Participation or Low Participation Rate As detailed in the full Quality Account in Section 5.2, there were some clinical audits that had a lower than expected participation rate. UHCW have investigated the reasons why this occurred and the reasons are described below. Audit title Participation Rationale for Low participation Rate Diabetes (National Adult Diabetes 71% Rugby St Cross submitted 100% data after Audit) downloading it from a clinical software system called DIAMOND. The Coventry site does not use this system and so due to time and resource constraints manually reviewed 280 cases out of a possible 886. However UHCW still believes this to be a significant sample. Heavy Menstrual Bleeding (RCOG 30% Patients had the choice not to complete the National Audit of HMB) questionnaire. The Questionnaire was 8 pages long which could have been off putting for patients. Secondly to be eligible to take part in the audit patients needed to be booked into the menorrhagia clinic rather than an outpatient clinic which was what was happening. For future rounds of this audit UHCW will put as much communication out to patients regarding the importance of taking part in this audit, and ensure that the patients are being booked into the right clinic in order to be eligible to participate. Chronic Pain (National Pain Audit) 51% This audit relied on patients returning a questionnaire back to Dr Foster who were collating the information. Dr Foster has advised that a 50% participation rate should be deemed good. For any future rounds of this audit UHCW will endeavour to put as much information out to patients about the importance of the audit to try and persuade them to return questionnaires. CABG and Valvular surgery (Adult 25% During the year the audit changed the way Cardiac surgery audit) that data needs to be submitted. Whilst this change occurred no data was entered. The UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
3
Audit title
Participation Rate
Rationale for Low participation Audit body recognised this was a problem for Trusts and has set a deadline date that all cases should be submitted by June 2012. UHCW will endeavour to submit all cases by this date.
The following table details those audits included on the Quality Account list published by the Department of Health in which UHCW did not participate and the reasons for the non-participation. Audit title Liver transplantation (NHSBT UK Transplant Registry) Intra-thoracic transplantation (NHSBT UK Transplant Registry) Schizophrenia (National Schizophrenia Audit) Prescribing in mental health services (POMH) Paediatric intensive care (PICANet) Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) Acute stroke (SINAP)
Risk factors (National Health Promotion in Hospitals Audit)
Cardiac arrest (National Cardiac Arrest Audit)
Medical Use of Blood (National Comparative audit of Blood Transfusion)
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
Rationale for non-participation Not eligible - Procedure not performed Not eligible - Procedure not performed Not eligible - Not Applicable to Acute Trusts Not eligible - Not Applicable to Acute trusts Not eligible - Service not provided Not eligible - Service not provided UHCW has participated in a comparable audit (SITS) and has been awaiting the start of the National Sentinel Stroke Audit (which has been delayed) in which the Trust has enrolled. Once the Sentinel Stroke Audit commences SINAP will become defunct. A Quality impact analysis (QIA)* was undertaken, the outcome of which was that the audit was not recommended to be undertaken. This was approved by the Chief Medical Officer. A local audit is currently being undertaken in conjunction with the PCT. UHCW is currently putting systems in place to guarantee 100% submission of the minimum data set required before registering. UHCW had participated in this Audit in 2011/2012. On checking the data entry to this audit we found a number of data quality issues which could not be rectified in time for the publication of the final report. UHCW could therefore not resubmit data, and was not prepared to submit inaccurate data so withdrew participation in June 2012 from this audit. UHCW will however in 2012/2013 undertake a local version of the same audit and will develop actions arising from it, and await the recommendations from the national report when it is published and act on them accordingly.
4
*A Quality Impact Assessment QIA is a tool that helps to prioritise the clinical audit projects the Trust could participate in to ensure effective prioritisation of audit work. The tool uses the following criteria for participating in an audit. • High frequency/volume service • High risk services • High cost • Potential for change • Existence of evidence based guidelines/ standards • Organisational fit • Direct impact on patients • Direct involvement with patients • Multidisciplinary project - level of involvement required • Interface project - level of involvement across various sectors Once assessed the risks and benefits will be explored with the specialties concerned.ebruary/ March
3. Actions Implemented following participation in National Audit An audit should be based on standards of good practice/outcomes and produce recommendations on how to improve both. The audit action plan should be a plan for turning recommendations (made following review of the audit results) into practice, therefore realising benefits for both patients and/or staff. The person/group who leads the audit is responsible for ensuring an action plan is developed and implemented in order to move onto the next stage of the audit cycle. The reports of 23 national clinical audits were reviewed by UHCW in 2011/2012. The following are brief summaries of some of the key actions we have taken to improve the quality of healthcare as a result of the review of national clinical audit reports: Title of Audit BTS Pleural Procedures 2011
National Hip Fracture Database 2011 (NHFD)
•
Key actions A new patient pathway for the Investigation and Management of Unilateral Pleural Effusions is being developed so patients requiring a pleural procedure can be more effectively managed.
•
A daily respiratory ward round is beginning to take place and patients are being prioritised to ensure they are moved to the correct ward faster.
•
The Respiratory ward will also have an ultrasound machine to allow clinicians to insert the majority of drains without having to move the patient. Introduction of formal weekend Consultant-led ward rounds of peri-operative patients
•
Appointment of a dedicated audit clerk on a permanent basis to undertake data entry into the NHFD. • A root cause analysis is carried out for patients before they commence on dialysis on venous access. This will ensure increased levels of patient safety. • Introduction of an Orthopaedic Enhanced Care Unit; •
National Kidney Care Audit report NCEPOD ‘An Age Old Problem’ – Emergency &
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
5
Title of Audit Elective Surgery in the Elderly
•
•
•
•
National Organisational Audit of Adult Inflammatory Bowel Disease Services National Audit of Dementia
• • •
• • • • •
Key actions Developed and agreed assessment tool to identify patients for surgery who would benefit from medical care of the elderly input which is due to be audited for validity during 2012/13; Consideration of implementation of P-Possum for prioritising emergency theatre cases according to risk; An audit of 80 patients has been undertaken to determine compliance with the Royal College of Surgeons time from booking to theatre standard with a more extensive audit planned in 2012/13; Development of a clinical guideline ‘Assessment and Management of Pain in Older People’. Funding has been secured for a second IBD nurse. Work has taken place with colorectal surgeons and the counselling services to try and link care. UHCW is also taking part in the UK IBD Biologics audit which is a national audit that contains information on IBD patients. A care pathway for patients with dementia is in place. Introduction of an assessment of mental state across the Trust. Introduction of a guideline for the management of patients with delirium. Increased training package for staff on how to manage patients with delirium or dementia. Embedding of a ‘getting to know me form’ - a formal system for capturing information on dementia patients social information, routines and preferences.
4. Local Audit
The reports of 93 local (not national) clinical audits were reviewed by UHCW in 2011/2012. The following are brief summaries of some of the key actions we have taken to improve the quality of healthcare as a result of the review of local clinical audit reports: Title of Audit Audit of the Rapid Access Chest Pain Clinic
•
• Upper Gastro Intestinal Bleed Audit
•
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
Key actions implemented A database has been developed to automatically calculate the score defined in NICE CG95 Guidelines for the Diagnosis of Chest Pain of Recent Onset. The clinic letter has been adapted to include the requirement to include the NICE score. A checklist and pathway have been created to ensure the correct clinical information is documented and that the patient follows the correct route and is seen by the appropriate staff member.
6
Title of Audit Audit of Management of Adrenal Incidentalomas
•
Audit of the Safe Use of Ciclosporin
•
•
• Hydration Assessment Audit •
Key actions implemented A Trust wide clinical guideline is being developed
Development of a systemics reference manual. This has been distributed around the department and is widely used. It will also been given to new members of staff to the department. A document has been written reminding nurses about the assessments needed for systemic agents. Hydration check list introduced to help nurses identify patients at risk and enable a more consistent approach Hydration assessment policy developed
Audit on pre-operative pain relief in fracture neck of femur patients
• •
Clinical guidelines have been developed A training programme is under development to teach fascia iliaca compartment block as an alternative method of pain relief to staff
Audit to identify the effectiveness of the Multiple Sclerosis Nursing Service at UHCW NHS Trust, in addressing the needs of people affected by Multiple Sclerosis upon referral to the service
•
Patients newly diagnosed with MS now receive an introductory letter which has been revised to include instructions on contacting the MS Specialist Nurses to book an appointment and discuss their diagnosis so additional support can be provided as required. Home visits are offered to patients with significant psychological and social problems as well as physical problems. Awareness raised of the 'What is MS?' publication and that it is available in other languages from the MS Society for patients where English is their second language.
•
•
Audit of Venous Thromboembolism (VTE) Risk Assessment in patients with Ischaemic Stroke: Two Weeks Later NPSA Safer Administration of Insulin
•
A system to provide an electronic reminder for clinicians when the re-assessment for VTE is due to be done has been implemented
•
All junior doctors have had a training session and this is hoped to be continued. There has been promotion of the e-learning tool for all staff on insulin administration. Posters have been developed to promote the safe use of insulin. A Trust wide action plan is in implementation, as maladministration of it is a Never Event. A patient information leaflet has been created along with posters of the patient pathway New registrars will be informed of the pathway and reminded to capture as much information possible. Monthly monitoring of call to balloon times with the
• • • Audit of Bone Protection Use with Oral Steroids
• •
Audit of Door to Balloon
•
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
7
Title of Audit Times in Primary PCI • Re-Audit of Ovarian Hyperstimulation Syndrome 2011
•
Audit of Massive Haemorrhage Protocol
•
•
• Is Naloxone being prescribed alongside every Patient Controlled Analgesia (PCA) prescription with the correct dosage and indication clearly visible? Re-audit of Secondary Prevention of Fragility Fractures in Post Menopausal Women who have sustained a #NOF
• • •
•
•
• Audit of Correct Surgical Site Marking in Elective Orthopaedic Patients at Rugby St Cross Hospital
•
NPSA Safer Use of Intravenous Gentamicin for Neonates (NPSA/2010/PSA001)
• •
• Audit of High Dependency Care for Obstetric Patients
• •
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
Key actions implemented results being displayed in the ED department and for the ambulance crews. Education sessions with the ambulance trust have been set up to inform the ambulance crews of the new pathway. Dendrite, a clinical system is being used to keep a record of recognised OHSS patients. Proforma from the Royal College of Obstetrician’s guidelines is being used to grade all the patients admitted with OHSS. A separate audit sheet is to be completed at time of MHP activation. Communication to staff to stand down if MHP is not required. All MHP activations logged by switchboard. BNF informed of ambiguity. Pre-written Naloxone stickers developed to be added to medicines chart with any PCA prescription. Education of medical students. Education to be provided to junior doctors at their induction on a continuous basis with regards to the guidelines for the management of fragility fractures in post menopausal woman who have sustained a fractured neck of femur. An information sheet has also been posted in the doctor’s mess raising awareness of the current guidelines. 70 marker pens distributed to all orthopaedic surgeons and clinical areas. A letter was also circulated to all Orthopaedic Surgeons highlighting the recommendations from this audit as follows:- patients should be marked precisely with an arrow - precision of marking should be improved for hip, foot, shoulder and hand cases - care needs to be given to ensure the mark remains fully visible for knee, hand, foot and hip cases Dissemination of current Gentamicin policies and practices to new medical and nursing staff. Review and revise neonatal Medicines Chart to include sections for the prescribing of Gentamicin and Vancomycin. Inclusion of check list on revised Medicines Charts prompting use of Gentamicin care bundle compliance chart and double checking prompt. Staff to record the NAME of the clinician outside of the maternity service referred to. Staff to write on continuation sheets and cross reference in the Yellow Perinatal Institute Notes.
8
Title of Audit • Immunisation of children with HIV
•
• •
Key actions implemented Review UHCW policy to make sure it complies with CNST 2012/13 HDU Guideline. Template to be developed to be inserted in patients notes to allow easier documentation of all immunisations Letters recommending what vaccinations to be sent also to parents and GPs To look into the implications of opportunistic vaccination in clinic e.g. cost, organisation, time.
For further information on Clinical Audit please contact the Quality and Effectiveness Department at;
[email protected], or 02476 968282
UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
9
University Hospitals Coventry and Warwickshire NHS Trust Quality and Effectiveness Department 5th Floor East Wing Clifford Bridge Road Coventry Warwickshire CV2 2DX Hospital of St Cross Barby Road Rugby CV22 5PX Coventry Switchboard: 024 76964000 Rugby Switchboard: 01788 572831 Website Address: www.uhcw.nhs.uk
Tel: 024 76968282 Email:
[email protected] UHCW Quality Account 2011-2012 Clinical Audit and Effectiveness Supplement
10
